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MILC-APIC TOOL
v1.4
Mother · Infant · Lactation — Assess · Plan · Implement · Check
Structured consultation form
Pharmaceutical care during lactation
Mark the appropriate option(s); fill the remaining fields with data.
Date of consultation
Provider / institution
Patient identifier
Do not enter personal data — use an ID or chart number.
Consultant details
Name, surname and licence (PWZ) number.
1
Clinical interview
MILC: Mother-Infant-Lactation
MILC
Reason for consultation & patient needs
Describe the needs and the reason for consultation.
Drug-Related Problem (DRP) screening
Problem status:
No problem
Potential problem
Actual problem
Specific problem (mark all that apply):
No effect of drug treatment despite correct use
Effect of drug treatment not optimal
No therapy despite indication
(Possible) adverse drug event occurring
Unnecessary drug treatment
Unclear problem / complaint
Describe the cause (if applicable)
Mother
Weight
in kg
Height
in cm
BMI
calculated automatically
Chronic conditions
Concomitant medications
Allergies
Lactation
Estimated share of mother's milk in the child's diet (mark one):
100 %
75 %
50 %
25 % and less
Breastfeeding problems before?
No
Yes
Baby additionally receives (mark all that apply):
Formula
Animal milk
Expressed mother's milk
Human donor milk
Parenteral nutrition
Solid foods
Comments regarding lactation
Infant
Age
Weight
Chronic conditions & current health status
Medications, supplements
Allergies
Medication(s) of concern
Medication name
Dose
Dosing regimen
Form
How long taken
2
Assess
Evidence review
Assess
Complete one Assess block per medication of concern (up to three). If a block is not needed, mark it “Not applicable” and leave it blank.
ASSESS · DRUG 1
primary medication
Medication assessed
Summary of Product Characteristics — SmPC (point 4.6)
Summarise the SmPC statement on use during lactation.
General risk of drug use during lactation (mark one):
No data
Very low risk
Low risk
Moderate risk
High risk
Very high risk
Assessment based on (mark all that apply):
No data
LactMed
InfantRisk App
Hale's Manual
Expert opinion
SmPC
e-lactancia
Clinical guidelines
Other:
How much of the drug passes into breastmilk?
M/P ratio
Oral bioavailability
Pediatric dose
Other data
Relative infant dose — RID (mark one):
No data
< 1 %
1–5 %
6–10 %
11–25 %
> 25 %
Can the amount of drug in breastmilk be clinically significant? (mark one):
No data
Yes
No
Not possible to assess
Reported adverse events on breastmilk / lactation (mark all that apply):
No data
None reported
Decreased milk supply
Increased milk supply
Change in milk colour
Change in milk taste
Change in milk odour
Change in milk flow
Other:
Reported adverse events in the breastfed child due to exposure (mark all that apply):
No data
Reported mild / self-limiting / few
Reported serious / requiring medical intervention
Reported isolated (specific to the individual situation)
Describe what was reported
Additional drug information
ASSESS · DRUG 2
additional medication
Not applicable — no further drug to assess (leave this block blank)
Medication assessed
Summary of Product Characteristics — SmPC (point 4.6)
Summarise the SmPC statement on use during lactation.
General risk of drug use during lactation (mark one):
No data
Very low risk
Low risk
Moderate risk
High risk
Very high risk
Assessment based on (mark all that apply):
No data
LactMed
InfantRisk App
Hale's Manual
Expert opinion
SmPC
e-lactancia
Clinical guidelines
Other:
How much of the drug passes into breastmilk?
M/P ratio
Oral bioavailability
Pediatric dose
Other data
Relative infant dose — RID (mark one):
No data
< 1 %
1–5 %
6–10 %
11–25 %
> 25 %
Can the amount of drug in breastmilk be clinically significant? (mark one):
No data
Yes
No
Not possible to assess
Reported adverse events on breastmilk / lactation (mark all that apply):
No data
None reported
Decreased milk supply
Increased milk supply
Change in milk colour
Change in milk taste
Change in milk odour
Change in milk flow
Other:
Reported adverse events in the breastfed child due to exposure (mark all that apply):
No data
Reported mild / self-limiting / few
Reported serious / requiring medical intervention
Reported isolated (specific to the individual situation)
Describe what was reported
Additional drug information
ASSESS · DRUG 3
additional medication
Not applicable — no further drug to assess (leave this block blank)
Medication assessed
Summary of Product Characteristics — SmPC (point 4.6)
Summarise the SmPC statement on use during lactation.
General risk of drug use during lactation (mark one):
No data
Very low risk
Low risk
Moderate risk
High risk
Very high risk
Assessment based on (mark all that apply):
No data
LactMed
InfantRisk App
Hale's Manual
Expert opinion
SmPC
e-lactancia
Clinical guidelines
Other:
How much of the drug passes into breastmilk?
M/P ratio
Oral bioavailability
Pediatric dose
Other data
Relative infant dose — RID (mark one):
No data
< 1 %
1–5 %
6–10 %
11–25 %
> 25 %
Can the amount of drug in breastmilk be clinically significant? (mark one):
No data
Yes
No
Not possible to assess
Reported adverse events on breastmilk / lactation (mark all that apply):
No data
None reported
Decreased milk supply
Increased milk supply
Change in milk colour
Change in milk taste
Change in milk odour
Change in milk flow
Other:
Reported adverse events in the breastfed child due to exposure (mark all that apply):
No data
Reported mild / self-limiting / few
Reported serious / requiring medical intervention
Reported isolated (specific to the individual situation)
Describe what was reported
Additional drug information
3
Plan & Implement
Planned interventions and how to implement them
PI
Describe the tailored intervention plan and the steps for implementation. Also enter here information for other specialists.
Qualification for other services:
None
New medication
Specialist consultation
Medicines review
Other:
4
Follow-up
Check outcomes & adherence
C
Follow-up date
Follow-up points to consider
Services provided
Based on (references / sources used)
Signature
Morze K, Szałek E, Waszyk-Nowaczyk M.
Poznan University of Medical Sciences